ANTIFON-CLIC®, a new clinical decision support system for the treatment of invasive aspergillosis: is it clinically relevant?

BACKGROUND: Invasive aspergillosis (IA) is increasing especially in new groups of patients. Despite advances in management, morbidity and mortality related to IA remain high. Thus, Clinical Decision Support System (CDSS) dedicated to IA are needed to promote the optimal antifungal for each group of patients. PATIENTS AND METHODS: This was a retrospective multicenter cohort study involving intensive care units and medical units. Adult patients who received caspofungin, isavuconazole, itraconazole, liposomal amphotericin B, posaconazole, or voriconazole, for the treatment of IA were eligible for enrollment. The primary objective was the concordance between the clinician's prescription and the prescription recommended by the CDSS. The secondary objective was the concordance according to different hospitals, departments, and indications. RESULTS: Eighty-eight patients (n=88) from three medical hospitals were included. The overall concordance was 97% (85/88) including 100% (41/41) for center A, 92% (23/25) for center B, and 95% (21/22) for center C. There was no significant difference in concordance among the hospitals (P=0.973), the departments (P=1.000), and the indications (P=0.799). The concordance was 70% (7/10) for isavuconazole due to its use as an empirical treatment and 100% (78/78) for the other antifungals. DISCUSSION: The concordance rate was high whatever the hospital, the department, and the indication. The only discrepancy was attributed to the use of isavuconazole as an empirical treatment which is a therapeutic option not included in the CDSS. CONCLUSIONS: This new CDSS dedicated to IA is meeting the clinical practice. Its implementation in routine will help to support antifungal stewardship.

Suboptimal exposure to fluconazole in critically ill patients: Pharmacokinetic analysis and determinants.

OBJECTIVES: This study aims at evaluating fluconazole exposure in critically ill patients and identifying variables associated with the latter. PATIENTS AND METHODS: This was a 2-year (2018-2019) retrospective multicenter cohort study. Adult patients > 18 years-old with at least one fluconazole concentration measurement during their ICU stay were included. RESULTS: Twenty patients were included. Only 11 patients had a fluconazole trough concentration (Cmin) within the target range (≥15 mg/L). According to bivariable analysis, SOFA score, GGT, fluconazole clearance, Ke, and Vd, were independently associated with a decrease in fluconazole Cmin. The median loading dose required to achieve the Cmin target appeared to be greater in patients with higher SOFA or GGT level and in patients undergoing renal replacement therapy. CONCLUSIONS: This study supports recommendation for routine fluconazole therapeutic drug monitoring in ICU patients so as to avoid underexposure, especially if SOFA score is ≥ 7 and/or GGT is ≥ 100 U/L.

Personalized bacteriophage therapy to treat pandrug-resistant spinal Pseudomonas aeruginosa infection.

Bone and joint infections (BJI) are one of the most difficult-to-treat bacterial infection, especially in the era of antimicrobial resistance. Lytic bacteriophages (phages for short) are natural viruses that can selectively target and kill bacteria. They are considered to have a high therapeutic potential for the treatment of severe bacterial infections and especially BJI, as they also target biofilms. Here we report on the management of a patient with a pandrug-resistant Pseudomonas aeruginosa spinal abscess who was treated with surgery and a personalized combination of phage therapy that was added to antibiotics. As the infecting P. aeruginosa strain was resistant to the phages developed by private companies that were contacted, we set up a unique European academic collaboration to find, produce and administer a personalized phage cocktail to the patient in due time. After two surgeries, despite bacterial persistence with expression of small colony variants, the patient healed with local and intravenous injections of purified phages as adjuvant therapy.

[Consumption of narcotics, substances assimilated to narcotics and psychotropic drugs in health establishments: Profile of a hospital from France and a hospital from Quebec]. / Consommation des stupéfiants, substances assimilées aux stupéfiants et psychotropes en établissement de santé : profil d'un hôpital français et d'un hôpital québécois.

OBJECTIVES: The objective was to describe the trends in the consumption of narcotic drugs, substances related to narcotic drugs (SAS) and psychotropic drugs between a French hospital and a Quebec hospital between 2013 and 2017. METHODS: This is a retrospective descriptive study. The consumption data was obtained from the pharmacy management software and was extracted by financial year (January 1st, 2013 to December 31st, 2017 for the French hospital and April 1st, 2013 to March 31st, 2018 for the Quebec hospital). For each drug considered to be narcotics, SAS and psychotropic drugs in France or subject to the legislation on designated substances in Quebec, we identified the quantities consumed from 2013 to 2017. The data werepresented according to the following therapeutic classes: opioids (N02A), other analgesics (N02B), anxiolytics (N05B), hypnotics and sedatives (N05C), general anesthetics (N01A), psychostimulants (N06B), androgens (G03B) and antagonists peripheral opioid receptors (A06A). The data were expressed as a defined daily dose (DDJ) for 1000 patient-days (PDs). RESULTS: In the French hospital, the consumption of narcotics, SAS and psychotropic drugs varied from 676 to 560 DDJ per 1000 PDs between 2013 and 2017. While it varied from 1019 to 756 DDJ per 1000 PDs between 2013 and 2017 in the Quebec hospital. In 2017, the most widely used therapeutic classes in French hospitals were, in decreasing order, anxiolytics (211 DDJ per 1000 PDs) (i.e. alprazolam), opioids (205 DDJ per 1000 PDs) (i.e. tramadol, morphine injectable) and hypnotics and sedatives (64 DDJ per 1000 PDs) (i.e. midazolam injectable). In Quebec hospitals, the three therapeutic classes the most used in 2017 were, in decreasing order, opioids (314 DDJ per 1000 PDs) (i.e. hydromorphone injectable, morphine injectable), anxiolytics (221 DDJ per 1000 PDs) (i.e. clobazam) and hypnotics and sedatives (108 DDJ per 1000 PDs) (i.e. midazolam injectable). CONCLUSION: This study notes a decrease in the consumption of opioids and other substances in both the French and Quebec establishments between 2013-2017. More work is needed to better describe the differences observed between the profile of each establishment. This is why monitoring consumption trends, therapeutic indications and preventive measures are essential.

[Contribution of a hospital pharmacy team to critical care of patients infected with SARS-CoV-2]. / Contribution d'une équipe de pharmacie hospitalière à la prise en charge en réanimation des patients infectés par le SARS-CoV-2.

With regard to the hospital drug supply chain, the safest system is the individual automated drug dispensing one provided by the pharmacy. For several years we have been trying to convince hospital decision-makers to set it up. In the meantime, to mitigate the risks of medication errors incurred by patients and caregivers, we have set up several work teams within the care units. These teams, made up of one pharmacist and one or two hospital pharmacy technicians, who notably manage the medicine cabinets in care units. The close collaboration with doctors and nurses developed over the years was a determining factor when it became necessary to provide the newly created additional intensive care units with drugs and medical devices (MDs) in order to cope with the crisis triggered by the SARS-CoV-2 epidemic. Daily monitoring of the drugs consumed by each patient, particularly neuromuscular blocking agents and MDs was a key element in managing stocks and anticipating changes of drugs, packaging and/or devices references. These facts give weight to the Claris report published in France which recognizes that the interactions of pharmacy technicians and pharmacists in the care units have positive effects in terms of quality and safety of patient care. They highlight the dangers to which patients and caregivers are exposed on Saturdays, Sundays and holidays when the pharmacy is closed. They legitimize the question of extending the opening of the pharmacy with a full team 365 days a year.

[Reorganization of clinical trial activity in a hospital pharmacy: Contribution of Lean management]. / Réorganisation de l'activité des essais cliniques dans une pharmacie à usage intérieur : contribution du Lean management.

OBJECTIVES: Hospital pharmacists are involved in clinical trials for the management of experimental drugs. In our hospital, the pharmacy is in charge of approximately 120 clinical trials and this activity is sub-divided between three sectors. The fragmentation of this activity generates difficulties in terms of heterogeneity of practices, redundancy of activities, and difficulties of communication with stakeholders outside the pharmacy due to the multiplicity of pharmaceutical interlocutors. The aims of this work were to improve and harmonize practices, and to reorganize and globalize the activities carried out in this sector. METHODS: A Lean management approach was employed. The process was mapped and then a double analysis was conducted. On the one hand, wastes and irritating were identified collaboratively, at project group meetings. On the other hand, a reorganization model was proposed. RESULTS: A diagnosis with 38 points to improve was drawn. The reorganization applied to human resources, by reducing the number of actors involved in a rational way, and secondly, tasks were revised and harmonized. CONCLUSIONS: The use of a lean methodology allowed us to perform successfully our reorganization. This approach led to continuous improvement in a collaborative manner in this sector.

Promoting oral potassium administration in a tertiary care hospital: An eleven-year study.

INTRODUCTION: Potassium is used to treat or prevent hypokalemia and exhibits all the characteristics of an intravenous to oral therapy conversion program. Despite this, the intravenous route for potassium replacement seems frequently unjustified. OBJECTIVES: To determine the impact of a conversion program on the use of intravenous and oral galenic forms in a university tertiary care hospital. METHODS: Two promotion campaigns were conducted in 2006 and 2009. The following years this was completed by pharmacist interventions during prescription analysis and face-to-face discussions with physicians during ward rounds. The consumption of products containing potassium was obtained by analyzing the hospital's financial database. RESULTS: The proportion of the oral route increased from 18% in 2006 to 22% in 2011, and from 25% in 2012 to 44% in 2016; the increase was significantly greater in the second period (P<0.0001). In 2016, in emergency, pulmonology, infectious diseases, and cardiology departments, the proportion of oral use ranged from 57% and 82%. The greatest progression from 2006 to 2016 was found for intensive care (4% vs. 12%) and visceral surgery departments (9% vs. 34%) that increased approximately four-fold, followed by the emergency department (28% vs. 57%) that increased approximately two-fold. CONCLUSION: Promoting the oral route for potassium replacement modifies prescriber habits and is followed by a notable increase in the proportion of potassium administered orally irrespective of department type.

Thesaurus for off-label indications for systemic antifungal agents.

OBJECTIVES: Following the removal of temporary treatment protocol procedures, we developed a thesaurus for off-label indications for systemic antifungals at our facility to update clinical practices and to control off-label prescriptions. MATERIALS AND METHODS: Clinical practice guidelines and literature data were analyzed. This work was part of an antifungal stewardship program. RESULTS: Off-label wording (prophylaxis, preemptive, empirical, curative) and corresponding antifungals and references were validated by the multidisciplinary group for antifungal agents under the aegis of the Commission for the use of drugs and sterile medical devices and of the anti-infective committee. CONCLUSION: Considering the complexity of invasive fungal infection management, this thesaurus needs to be shared and used as a helping tool to review off-label situations.

A systematic review of interventions and performance measures for antifungal stewardship programmes.

Objectives: Antifungal resistance is a significant and emerging threat. Stewardship programmes (SPs) have been proposed as an opportunity to optimize antifungal use. While examples of antifungal SP implementation have been recently described, there is yet to be an overview of interventions and their impacts on performance measures. Methods: We systematically reviewed published articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses check-list 2009. MEDLINE was searched using the term 'antifungal stewardship' on 15 February 2017. Eligible studies were those that described an antifungal SP and included an intervention and an evaluation of performance measures. Results: A total of 97 studies were identified and 14 were included. Only five studies reported an antifungal stewardship team composed of all the recommended members. The main intervention was the formulation of recommendations to change treatment (12 of 14). The main performance measure collected was antifungal consumption (10 of 14), followed by antifungal expenditure (7 of 14), adherence to therapeutic advice (4 of 14) and impact on mortality (4 of 14). Antifungal consumption was reduced by 11.8% to 71% and antifungal expenditure by as much as 50%. Adherence to therapeutic advice ranged from 40% to 88%, whereas antifungal SPs had no impact on mortality. Conclusions: All antifungal SPs had an impact, in particular on antifungal consumption and antifungal expenditure. Active intervention including a review of prescriptions seems to have more impact than implementation of treatment guidelines only. According to available published studies, antifungal consumption appears to be the most achievable performance measure to evaluate the impact of an antifungal SP.

[Off-label use of intravenous immunoglobulin therapy in the treatment of lupus myocarditis: Two case reports and literature review]. / Utilisation hors AMM d'immunoglobulines intraveineuses dans le traitement de la myocardite lupique : à propos de deux cas et revue de la littérature.

INTRODUCTION: Several case reports have reported the benefit of intravenous immunoglobulin therapy in many autoimmune diseases, including systemic lupus erythematosus. CASE REPORTS: Here, we report on two cases of lupus myocarditis treated with high dose of intravenous immunoglobulin. The first patient was a 42-year-old woman who presented with lupus myocarditis that was resistant to corticosteroids and cyclophosphamide, and who was finally successfully treated with a single dose of 2 g/kg of intravenous immunoglobulin. The patient displayed clinical improvement a few days later. The second case - a 43-year-old woman was diagnosed with lupus myocarditis and immunosuppressive drugs were contraindicated because of the context of a recent infective endocarditis. She was treated with repeated dose of 2 g/kg of intravenous immunoglobulin. Clinical improvement was observed and the left ventricular ejection fraction increased from 20 % to 60 % within a few days. We also report 9 similar observations identified from a literature review. CONCLUSION: The use of intravenous immunoglobulin in lupus myocarditis is not officially recognized but could be considered as an alternative when conventional therapies have failed or are contraindicated.

[Medication errors with concentrated potassium intravenous solutions: Data of the literature, context and prevention]. / Erreurs médicamenteuses avec les solutés concentrés de potassium injectable: données de la littérature, état des lieux et prévention.

Accidental direct intravenous injection of a concentrated solution of potassium often leads to patient death. In France, recommendations of healthcare agencies to prevent such accidents cover only preparation and intravenous infusion conditions. Accidents continue to occur in French hospitals. These facts demonstrate that these recommendations are insufficient and ineffective to prevent such deaths, especially those occurring during a catheter flushing. This article reviews the measures able to reduce the number of accidents. Countries which removed concentrated ampoules from ward stocks observed a decrease of the number of accidental deaths. This withdrawal, recommended by the World Health Organization, is now part of standards in studies aimed at determining the safety of care in hospitals. However, removal alone is insufficient to eliminate the risk. The combination with other measures should be considered. These measures are the provision of a combination of diluted intravenous ready to use solutions, the promotion of the oral route with tablets and oral solutions for potassium replenishment and to make available products with safeguards to prevent single shot intravenous injection. Studies aimed at determining the consequences on preventing concentrated potassium accidents of a widespread distribution of isotonic sodium chloride pre-filled ready-to-use syringes for catheter flushing should be performed.

[Pharmacist's interventions on outpatient prescriptions in a university hospital drugs sales service]. / Interventions des pharmaciens sur les prescriptions ambulatoires dans le cadre de l'activité de rétrocession d'un centre hospitalier universitaire.

UNLABELLED: For public health reasons, some drugs are only available in hospital drugs sales service. This activity takes place in a specific risk context of organization, patients and/or drugs. A systematic prescription analysis by pharmacist contributes to securise treatment dispensed. The aim of this paper is to present the main drugs problems in the analysis of outpatient prescriptions and pharmaceutical interventions in three units of hospital drugs sales service belong to university hospital. METHODS: Throughout the year 2013, drug problems detected were recorded prospectively and systematically. RESULTS: Of the 22,279 prescriptions analyzed, 247 pharmaceutical interventions (1.1%) were detected including 27.6% of problems concerning the dosages, 15.4% the unconformity, 6.9% contraindications. Regarding ATC drugs classes, we found 43.7% for anti-infectives and 17.4% for antineoplatics. The overall acceptance rate is 81.8%. CONCLUSION: These results show the importance of the analysis of outpatient prescriptions before dispensing and the need to have all prescriptions, clinical and biological elements and to develop interprofessionality. The implementation of a platform for dematerialized data exchanges between professionals, including data from the pharmaceutical patient record should contribute to improving drug management of the patient.

Patients' knowledge about paracetamol (acetaminophen): a study in a French hospital emergency department.

UNLABELLED: Paracetamol is the most widely used analgesic and antipyretic drug. In France, little is known concerning patients' knowledge and beliefs about paracetamol. OBJECTIVE: To determine how much outpatients attending an emergency department know about paracetamol. METHOD: A semi-structured questionnaire was applied to patients consulting for non-severe medical or traumatic conditions. RESULTS: Thirty-three (45%) of 73 participating patients knew that paracetamol was the active ingredient of the medication they used to reduce pain and/or fever. Three patients thought 2g was the maximum recommended single dose; 25% thought that a delay between two doses ≤ 3 hours was recommended and 15% thought the maximum daily dose was > 4 g. While 8% cited liver toxicity as a side effect, 38% did not believe an excessive dose could be fatal. Two patients correctly answered all questions and five gave no correct answer. DISCUSSION: Outpatients attending an emergency department (ED) have poor knowledge about paracetamol. This situation is disturbing and our results may serve as an eye opener to healthcare professionals. They emphasize the need for research programs with the following objectives: a) to determine the actual content of the message delivered by healthcare professionals; b) to study conditions under which this message is issued; c) to analyze how patients understand key messages and what their behavioral response is. CONCLUSION: In ED patients, the level of knowledge about paracetamol is insufficient to ensure its safe use in ambulatory care. Further studies are needed to determine the causes and to permit better patient education.

A potential role for parasites in the maintenance of color polymorphism in urban birds.

Urbanization is a major challenge for biodiversity conservation, yet the evolutionary processes taking place in urbanized areas remain poorly known. Human activities in cities set new selective forces in motion which need to be investigated to predict the evolutionary responses of animal species living in urban areas. In this study, we investigated the role of urbanization and parasites in the maintenance of melanin-based color polymorphism in the feral pigeon Columba livia. Using a correlative approach, we tested whether differently colored genotypes displayed alternative phenotypic responses to urbanization, by comparing body condition, blood parasite prevalence and parasite load between colored morphs along an urbanization gradient. Body condition did not vary with urbanization, but paler individuals had a higher body condition than darker individuals. Moreover, paler morphs were less often parasitized than darker morphs in moderately urbanized habitats, but their parasite prevalence increased with urbanization. In contrast, darker morphs had similar parasite prevalence along the urbanization gradient. This suggests that paler morphs did better than darker morphs in moderately urbanized environments but were negatively affected by increasing urbanization, while darker morphs performed equally in all environments. Thus, differently colored individuals were distributed non-randomly across the urban habitat and suffered different parasite risk according to their location (a gene-by-environment interaction). This suggests that melanin-based coloration might reflect alternative strategies to cope with urbanization via different exposure or susceptibility to parasites. Spatial variability of parasite pressures linked with urbanization may, thus, play a central role in the maintenance of plumage color polymorphism in this urban species.

Overdosed prescription of paracetamol (acetaminophen) in a teaching hospital.

INTRODUCTION: Paracetamol is the most commonly used analgesic and antipyretic. Reviews of hospital use of paracetamol are scarce. Little is known about the appropriateness of the dose of paracetamol prescribed for hospitalized adults. The aim of this study was to report on the nature and the frequency of the overdosed prescription of paracetamol observed in adult patients over a 4.5-year period in a teaching hospital. METHODS: Prescription analysis by pharmacists was performed once a week in six medical and three surgical departments and daily in a post-emergency unit. In cases of prescription error, the pharmacist notified the physician through an electronic alert when a computerized prescription order entry system was available or otherwise by face-to-face discussion. For each drug-related problem detected, the pharmacists recorded relevant details in a database. RESULTS: From October 2006 to April 2011, 44,404 prescriptions were reviewed and 480 alerts related to the overdosed prescription of paracetamol were made (1% of analyzed prescriptions). The extent of errors of dosage was within the intervals [90-120 mg/kg/d] and greater than 120 mg/kg/d for 87 and 11 patients respectively, who were prescribed a single non-combination paracetamol containing product. Sixty alerts concerned co-prescription of at least two paracetamol containing products with similar frequency for computerized (1.4/1000) or handwritten (1.2/1000) prescriptions. DISCUSSION: Prescriptions of paracetamol for hospitalized adults frequently exceed the recommended dosage. CONCLUSION: These results highlight the need for increased awareness of unintentional paracetamol overdose and support the initiation of an educational program aimed at physicians and nurses.

Prescriptions analysis by clinical pharmacists in the post-operative period: a 4-year prospective study.

BACKGROUND: Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. METHODS: In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. RESULTS: Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug-drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. CONCLUSION: Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures.

[Results of a satisfaction survey carried out among patients living with the virus of human immunodeficiency (HIV) following therapeutic education sessions]. / Résultats d'une enquête de satisfaction réalisée auprès des patients vivant avec le virus de l'immunodéficience humaine (VIH) suivis en consultation d'éducation thérapeutique.

INTRODUCTION: Within the framework of a quality initiative aiming to improve HIV patients' care in our therapeutic educational unit, and to meet the recommendations of the Haute Autorité de Santé (HAS) regarding the evaluation of educational programs, we carried out a satisfaction survey among patients. Our goal was to identify their needs thanks to the analysis of questionnaires in order to improve their care. PATIENTS AND METHOD: Anonymous questionnaires were proposed and collected for two months during a medical or educational consultation or during a renewal of prescription. All 21 questions related to the organization of our unit, the patients' expectations, the tools used and the quality of life. An appreciation scale at four levels was proposed. RESULTS: Twenty-eight questionnaires were returned out of 60 given out; 96.4% of the patients were satisfied and found the sessions to be beneficial and to answer their needs; 85.7% changed their opinion on HIV and 78.6% altered their behaviour; 89.3% were satisfied by the number of sessions; 96.4% thought that the place, duration and frequency of consultations were adapted, and 89.3% approved the educational tools; 67.8% thought that follow-up pad would be useful. DISCUSSION-CONCLUSION: Patients were satisfied with the educational sessions, which constituted a real place of exchange and support, allowing them to evoke all the difficulties they meet. Any improvements must concern information media given out to patients and the ease of access to educational teams in case of difficulties.

Assessment of sodium hyaluronate gel as vehicle for intracameral delivery of cefuroxime in endophthalmitis prophylaxis.

Sodium cefuroxime is a second-generation cephalosporin widely used at 10mg/mL for endophthalmitis prophylaxis after cataract surgery. Sodium cefuroxime solution is usually conditioned in pre-filled syringes then frozen for storage. In the present study, 0.2% sodium hyaluronate gel, natural extracellular polymer used in wound healing, was compared to conventional saline solution (0.9% sodium chloride) as drug delivery systems for cefuroxime loading in pre-filled syringes. Therefore, the temperature (4 and 25 degrees C) and time of storage (up to 21 days) varied in order to appreciate both cefuroxime and vehicle stability. Furthermore, the kinetics of drug release from both hyaluronate gel and saline solution were compared since in vitro sets of dialysis experiments. Results indicated that cefuroxime loaded in either saline solution or hyaluronate hydrogel was found stable in pre-filled syringes stored at 4 degrees C for 21 days, whereas cefuroxime degradations products appeared from the 2nd day of storage at 25 degrees C. Both drug delivery systems were found bioequivalent, although statistically slower cefuroxime dialysis was evidenced by using sodium hyaluronate vehicle. Noteworthy, cefuroxime concentration in drug delivery systems during dialysis experiment remained greater than the minimum inhibitory concentrations reported for resistant strains. In conclusion, the present stability and release study confirmed that sodium hyaluronate hydrogel is a promising vehicle for cefuroxime intracameral delivery in endophthalmitis prophylaxis.

[Accidental intravenous injection of potassium chloride: analysis of contributing factors and barriers to risk reduction]. / Injection intraveineuse accidentelle de chlorure de potassium : facteurs contributifs et obstacles à la réduction du risque.

Errors linked to injectable potassium chloride (KCl) have been the cause of deaths which have occurred for many years. Following an accidental direct intravenous injection of KCl of no clinical consequence for the patient, we have analyzed the contributive factors, established an action plan to prevent this risk and finally assessed its impact. Among the causes leading to medication errors, we have identified those linked to the handling of the drugs by nurses, the team, the work conditions, the organization, the institutional context and finally to the drug itself. The risk reduction procedure involved a withdrawal of injectable KCI ampoules from wards, possible in 52% of the care units, a reorganization of storage for the others. The subsequent monitoring of floorstocks revealed that these measures were insufficient and that the risks prevailed due to the presence of KCI ampoules in drawers assigned to other ionic solutions. A study carried out among the medical and nursing personnel revealed that 61.2% of the doctors thought that the risk existed in their ward and 68% of the nurses considered themselves to be exposed to the risk of a medication error. The drug supply chain of our institution, as in numerous others, is not safe. Hospitals are not yet organized adequately to prevent the occurrence of such an error. The comparison with foreign organizations of drug dispensation allows us to think that the improvement and professionalization of the drug supply chain will both be assets in the prevention of such medication errors.

[Pharmaceutical counselling and evaluation of the knowledge of hospitalized patients treated with anti-vitamin K drugs]. / Consultation de pharmacie et niveau de connaissance des patients hospitalisés traités par des médicaments anti-vitamine K.

The report published by the French Agency for the Medical Safety of Health Products in 2001 estimated the number of hospital admissions in France for hemorrhagic accidents caused by oral anticoagulants (OA) to be 17,000. For this reason, we have set up pharmaceutical counselling for hospitalized patients treated with OA. The object of this article is to describe this therapeutic education program and to present the level of knowledge that patients have of their OA treatment. Among 68 patients treated prior to their admission, 87% knew the name of the OA, 86% the role of this treatment, 80% the dosing schedule, 57% what to do if a dose had been forgotten, 34% the signs of overdose, 48% the signs of and risks associated with not following the treatment schedule, 94% the advantage of biological follow-up and 68% the principal combinations of drugs that should be avoided. Among 118 patients whose treatment was begun during hospitalization, the level of knowledge for each item were respectively: 41%, 61%, 38%, 37%, 19%, 23%, 34% and 24% at the time of counselling. Newly treated patients acquired their knowledge from contact with nurses. The least known items were the symptoms and risks associated with overdosing or underdosing. This knowledge is therefore fragmentary and does not guarantee the patients' safety, which justifies the proposition of this type of counselling to such hospitalized patients.